Pregnant women with severe hypertension
(systolic over 160 mmHg, diastolic 110 mmHg or more) are a
vulnerable group for serious maternal and fetal/neonatal
complications, hence prompt and adequate control of
hypertensive crisis is vital in the obstetric population.

The mainstay of the management of
hypertensive crisis remains antihypertensive therapy. The
aim of antihypertensive therapy is to lower blood pressure
quickly but safely, to avoid complications and to prevent
end-organ damage to the mother and the fetus. The target BP
is systolic between 140-160 and diastolic between 90-110 mm
Hg. The most recent Cochrane systematic review1 considered
the effectiveness of anti-hypertensives for treatment of
severe hypertension during pregnancy and concluded that
there is no evidence that one antihypertensive agent is
preferable to the others for improving outcome for women
with very high blood pressure during pregnancy, and their
babies. They concluded that until better evidence is
available, the choice of antihypertensive should depend on
what is known about adverse drug effects and how familiar
the clinician is with a particular drug. Parenteral
Hydralazine, parenteral Labetalol and oral Nifedipine are
currently accepted for management of severe hypertension in
pregnancy. The drug administration protocols2,3,4 are as
given in box 1-3. If IV access is not yet obtained and
treatment for acute-onset, severe hypertension is urgently
needed, a 200-mg dose of labetalol can be administered
orally and repeated in 30 minutes if an appropriate
improvement is not observed.

Magnesium sulfate is not recommended as an
antihypertensive agent, but magnesium sulfate remains the
drug of choice for seizure prophylaxis in severe
preeclampsia.

Once the hypertensive emergency is treated, a complete
and detailed evaluation of maternal and fetal well-being is
needed with consideration of the need for subsequent
pharmacotherapy and the appropriate timing of delivery.
Biochemical investigations to rule out maternal
complications of preeclampsia (complete blood count, liver
function tests, coagulation profile, renal function tests)
and intrapartum cardiotocography for fetal surveillance are
to be performed.
The general consensus would be induction of labour
especially if the pregnancy has crossed 34 weeks of
gestation. The severity of disease and maternal/ fetal
condition may still be the deciding factor for practitioners
at this stage.
Monitoring/observations

Initial monitoring/observations:

• Record blood pressure readings EVERY 5 MINUTES on the
electronic partogram during administration of IV /loading
dose.
• Continue observation of BP every 15 minutes until the BP
is maintained at 140-160/ 90-100mmHg for two hours.
• The frequency of blood pressure monitoring can then be
reduced to every 30 minutes for the duration of the
infusion.